1962646265 NPI number — LOVELACE HEALTH SYSTEMS INC

Table of content: (NPI 1962646265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962646265 NPI number — LOVELACE HEALTH SYSTEMS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOVELACE HEALTH SYSTEMS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LOVELACE SPECIALTY PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962646265
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
11/09/2011
NPI Reactivation Date:
11/22/2011

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 27803
Provider Second Line Business Mailing Address:
PHARMACY FINANCE
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87125-7803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-727-1273
Provider Business Mailing Address Fax Number:
505-727-7439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 WALTER ST NE
Provider Second Line Business Practice Location Address:
SUITE 202B
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87102-2534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-727-1299
Provider Business Practice Location Address Fax Number:
505-727-2990
Provider Enumeration Date:
04/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
TROM
Authorized Official First Name:
BRAD
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
505-727-1299

Provider Taxonomy Codes

  • Taxonomy code: 3336S0011X , with the licence number:  PH00003167 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 371068 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2120305 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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